-- Special Exposure Cohort Petition U.S. Department of Health and 

under the Energy Employees Occupational Centers for D~sease Control and Prevention 

illness Compensatron Act National Institute for Occupat~onal Safety and Health 

OM5 Number 0920-0639 Expires: 05/31/2007 Special Exposure Cohort Petition - Form B Page I of 7 

use of.this form and disclosure of Social Security Number are voluntary. ~ailure to.use this fo&oi disclose 

::this number will not result in the denial of any right, benefit,or privilege to which you may be entitled. 

General Instructions on Completing thls Form (complete ~nstrucbons are avadable In a separate packet): I Except for signatures, please PRINT all information clearly and neatly on the form. I 

Please read each of Parts A - G in this form and complete the parts appropriate to you. If there is more 

than one ~etitioner, then each petitioner should complete those sections of parts A - C of the form that apply 

to them. Additional copies of the first two pages of this form are provided at the end of the form for this purpose. A maximum of three petitioners is allowed. 

I If you need more space to provide add~tional lnforrnat~on. Lse the continuat'on page provided at the end of 

rhe form and attach the complered conrlnuatlon page(s) to Form B. I 

If you have questions about the use of this form, please call the following NlOSH toll-free phone number and 

request to speak to someone in the Office of compensation Analysis and Support about an SEC petition: 

1-800-356-4674, 

10 A Labor Organization. Start at D on Page 3 

.2 Organization Information: 

If you 

are: 

I Name of Organization I 

0 An Energy Employee (current or former), Start at C on Page 2 

$if A Sulvivor (of a former Energy Employee), Start at B on Page 2. 

3 A Representative (of a current or former Energy Empioyee). Start at A on Page 1 

Position of Contact Person 

A.3 Name of Petitlon Representative: 

Mr.lMrs.lMs. First Name Middle Initial Last Name 

A.4 Address: 

1 Street Apt # P.O. Box I 

City State Zip Code 

A.5 Telephone Number: ( 

A.6 Email Address: 

A.7 O Check the box at left to indicate you have attached to the back of this form written authorization to 

petition by the survivor(s) or employee(s) indicated in Parts B or C of this form. An authorization 

. . . . . . ., 1 If you ani~p'rese~in~~uwi~or, .- - 

gooto Part B; ifpu anrepre~ntinp.~n'~~plo~g0'~to ~iit'c~;: 1 - . .. - . . . A . . -. . - . -- 

Name or Social Security Number of First Petitioner: - 

t 
U.S. Department of Health and Human Services 

under the Energy Employees Occupat~onal Centers for Disease Control and Prevention 

Illness Cornpensatton AU National Institute for Occupational Safety and Health 

OMB Number: 0920-0639 Expires: 

Mr.iMrs.lMs. First Name Middle initiai 

- Last Name .- 8.2 Social Security Number of Survivor: -, 

8.3 Address .- . of Survivor: A 

Street ' ,'7 .+ ~pt # -. . .- P.O. Box 

.~ .-... - City State Zip Code 

3.4 Telephone Number of Survivc.. - 

.-.. 8.5 Emall Address of Survivor: 

6.6 Relationship to ~m~lo~ee: t 

Go to Part C. 

C Name of Emulovee: 

... < ,.. . . (%~r.l~rs.l~s. First Name Middle initial Last Name 

C.2 Former Name of Employee (e.g., maiden nameliegal name changelother): 

Mr.lM s.lMs. First Name I +A Middle initial Last Name 

C.3 Social Security Number of Employee: 

C.4 Address of Employee (if living): 

Street Apt # P.O. Box 

State Zip Code I 

Telephone Number of Employee: I I 

Email Address of Employee: 

Employment Information Related to Petition: 

Employee Number (if known): 

Dates of Employment: Start b)~/~-+ End 6/30/5-~ 

Employer Name: /-/OR )9od5. /arc - . 

Work Site Location: CLE VE LA-0 

Supervisor's Name: 

t Go to Part E. I 

Name or Social Security Number of First Petitioner: L 
Special Exposure Cohort Petition 

under the Energy Employees Occupat~onal 

Illness Cornpensallon Act 

U.S Department of Health and Human Servlces 

Cel'en for D sease Cocrro ana ire$enl on 

N.?:cn? 'ns'i'de 'or Occc3alo-a Safer, 3~2 ned In 

.Ye- -.--- 

Mr.lMrs.lMs. ~irst Name Middle lnitiai - - Last Name - 

Social Security Number of Survivor: 

Address .- . of Survivor: - -1 

Street ' ,7 r Apt # A,. - .- 

P.O. Box 

- - 

City State Zip Code 

Telephone Number of Surviv . . - Emall Address of Survivor: . . . . . -. 

Relationship to ~mplo~ee: 

I C 1 

Name of Empioyee: I - - . ., I mri.!~s. First Name Middle Initial Last Name I 

] c.2 Former Name of Employee (e.g.. maiden nameilegal name changelother): 

I I 

Mr.1~~s.l~~. First Name Middle Initial Last Name 

I C.3 Social Security Number of Employ 

C.4 Address of Employee (if living): 

I Street 

- 1 

Apt # P.O. Box I 

City State Zip Code 

Telephone Number of Employee: I I 

Emaii Address of Employee: 

Employment Information Related to Petition: 

Employee Number (if known): 

Dates of Employment: Start 

Employer Name: --/o~i?&hl~ - /$& 

Work Site Location: - - .. 

-- 

Supervisor's Name: 

Name or Social Security Number of Flrst Petitioner: - - 
Name of Organization 

Position of Contact Person 

D.2 ~ame of Petition Representative: 

D.3 Address of Petition Representative: 

D.4 Telephone Number of Petition Representative: I 

D.5 Email Address of Petition Representative: 

D.6 Period during which labor organization represented employees covered by this petition 

(please attach documentation): Start End 

D.7 Identity of other labor organizations that may represent or have represented thls class of 

employees (if known): 

*~ Go to Part E. ..,..a, ,... : . . ~ .,<- . .. . .. .~. .,..-...*,..., ?.,.. ...+. 

Name or Social Security Number of First Petitioner: 
U.S. Department of Health 

under the Energy Employees Occupat~onai Centers for Disease Control and Prevention Illness Cornpensat~on Act National Institute for Occupatlonat Safetyand Health 

OM6 Number: 0920-0639 Expires: 

El Name of DOE or I' 

to this petition: 

. Fhcc~lry : -An)? K,q -1 

E.3 List job titles andlor job duties of employees included In the class. In addition, you can list by 

name any individuals other than petitioners identified on this form who you believeshould be 

included in this class: 

-&T/W.~ €$C.IACCC;O &.fiI) ALL DX~R ~A~~cD~

E.4 Employment Dates relevant to this petition: 

Start b/( / ffq- End 4'/30/57 

Start End 

Start End 

E.5 Is the petition based on one or more unmonitored, nrecorded, or inadequately monitored or 

recorded exposure Incidents?: P Yes $No Po (;NU LC &up 

(f PAVE d3 kdi;ui c,). J~ NT 

If yes, provide thecdatef4 odhe inc&nt&and$cLo&6e deklption (attach additional pages 

as necessary): 

.*w .~.?-: .. .. .. . . . .* .,,, . Goto Part F. .. . .. . , < ;~:.:. ~-:,. . . . '>.ti, 

Name or Social Security Number of First Petitioner: - - 
Special Exposure Cohort Petition 

under the Enerw, Employees Occupa!!cnsl 

1 Illness C0npeosa;lon Act 

Department of Health and Human Services; 

Centers fa, Dtsezse Control and Prevention 

Nz!ional lnsttule far Occupational Saieq and Health 

i OM6 Number: 0920-0639 

c~~~~:~,, -.i at least one of t.ie !oilot%,i:~g e8ii.e~ n :r,s secr:o~; hy checkl~:~~ the app:oprla!e box arid providiiiy 

the reo,uired iiforrnat'on reiated 13 the selecton. Y~LI are rot reqwed to cornpiete more than one ently. 

F 1 iiZh.'e have attached either documents or statements provided by affidavit that indicate that 

radiation exposures and radiation doses potentially incurred by members of the proposed ciass, 

that relate to this petition. were not monitored. either through personal monitoring or through areE 

moiiitoring 

1 (Attach docunients andior affidavits to the back oi the petition form.) 

Describe as completely as possibie, to the extent it might be unclear. how the attached 

doctiinentation andlor affidavlt(s) indicate that potential radiation exposures were not monitored. - i .4m .sd~rn ,~r,ji j~,, -5~~ ,-~m=-d: odrHcr /OgCo - 

. c , cc , OF TM~-AFG& 

. B.+RL-(~,S AN^ J&fpGt~. TiC- / 

N .(.dhntziic.i 15 'G rfl'? -4~- 

ri~~ 0 3 FOP. F&.L(.,m~ -' OF T? 11 to6:;-12~-,4 , 

F 2 CI il We have attached either docunients or statements provided by affidavit that indicate that 

radiation monitoring records for members of the proposed class have been lost, falsified, or 

destroyed; or that there is no information regarding monitoring, source, source term. or process 

from the site where the employees worked. 

(Attach docu~nents andlor affidavits to tile back of the petition form.) 

Describe as compieteiy as possibie to the extent it might be unclear. how the attached 

documentation andlor affidavit(s) indcate that radiation inonitoring records for members of the 

proposed class have been lost, altered ~llegally, or destroyed. 

Part F is continued on the following page. 

Name or Social Security Number of First Petitioner: 
U.S. Department of Health and Human Services 

under the Energy Employees Occupational Centers for Disease Control and Prevention 

Illness Compensation Act Natlonal Institute for Occupational Safety and Health 

OMB Number: 0920-0639 Expires: 05/31/2007 

Special Exposure Cohort Petition -Form B Page 6 of 7 

F.3 O i/We have attached a report from a health physicist or other individual with expertise in 

radiation dose reconstruction documenting the limitations of existing DOE or AWE records on 

radiation exposures at the facility, as relevant to the petition. The report specifies the basis for 

believing these documented limitations might prevent the completion of dose reconstructions for 

members of the class under 42 CFR Part 82 and related NlOSH technical implementation 

guidelines. 

. (Attach report to the back of the petition form.) 

F.4 O lMle have attached a scientific or technical report, issued by a government agency of the 

Executive Branch of Government or the General Accounting Office, the Nuclear Regulatory 

Commission, or the Defense Nuclear Facilities Safety Board, or published in a peer-reviewed 

journal, that identifies dosimetry and related information that are unavailable (due to either a lack 

of monitoring or the destruction or loss of records) for estimating the radiation doses of 

employees covered by the petition. 

(Attach report to the back of the petition form.) 

Go to Part G. 

~ ~ ~ ~ ~ IAII Petitioners should sign and A maximum of three persons may sign the petition. I A 

--. - Signature 

I Signature Date I 

Signature Date 

Notice: Any person who knowingly makes any false statement, misrepresentation, concealment of 

fact or any other act of fraud to obtain compensation as provided under EEOICPA or who 

knowingly accepts compensation to which that person is not entitled is subject to civil or 

administrative remedies as well as felony criminal prosecution and may, under appropriate 

criminal provisions, be punished by a fine or imprisonment or both. I affirm that the information 

provided on this form is accurate and true. 

Send this form to: SEC Petition 

Office of Compensation Analysis and Support 

NlOSH 

4676 Columbia Parkway, MS-C-47 

Cincinnati, OH 45226 

If ther~.areadditional~petitioners, they must complete the AppendiaF~rms foradditibnalipetifiB.ners:. . . 

.. . . ' . .: . :. ... The Appendix forms areldcated.attthe.end of;this:document- '' ':. ::-:.: ... - ,.. I; 

>.. 

Name or Social Security Number of First Petitioner: 
Special Exposure Cohort Petition U.S. Department of Health and Human Services 

under the Energy Employees Occupational Centers for Disease Contml and Prevention i Illness Compensation Act National Institute for Occupational Safely and Health 

OM5 Number: 0920.0639 Expires: 05/3112007 

Speclal Exposure Cohort Petition - Form B Page 7 of 7 

Public Burden Statement 

Public reporting burden for this collection of information is estimated to average 300 minutes per response, 

including time for reviewing instructions, gathering the information needed, and completing the form. If you 

have any comments regarding the burden estimate or any other aspect of this collection of information. 

including suggestions for reducing this burden, send them to CDC Reports Clearance Officer, 1600 Clifton 

Road, MS-E-11, Atlanta GA, 30333; ATTN:PRA 0920-0639. Do not send the completed petition form to this 

address. Completed petitions are to be submitted to NiOSH at the address provided in these instructions. 

Persons are not required to respond to the information collected on this form unless it displays a currently 

valid OMB number. 

I Privacy Act Advisement I 

In accordance with the Privacy Act of 1974. as amended (5 U.S.C. § 552a). you are hereby notified of the 

following: 

The Energy Employees Occupational illness Compensation Program Act (42 U.S.C. §§ 7384-7385) 

(EEOICPA) authorizes the President to designate additional classes of employees to be included in the 

Special Exposure Cohort (SEC). EEOICPA authorizes HHS to implement its responsibilities with the 

assistance of the National Institute for Occupational Safety (NIOSH), an Institute of the Centers for Disease 

Control and Prevention, Information obtained by NlOSH in connection with petitions for including additional 

classes of employees in the SEC will be used to evaluate the petition and report findings to the Advisory 

Board on Radiation and Worker Health and HHS. 

I 

Records containing identifiable information become part of an existing NlOSH system of records under the 

Privacy Act, 0S20-147 "Occupational Health Epidemiological Studies and EEOICPA Program Records. 

HHSICDCINIOSH." These records are treated in a confidential manner, unless otherwise compelled by law. 

Disclosures that NlOSH may need to make for the processing of your petition or other purposes are listed 

below. 

NlOSH may need to disclose personal identifying information to: (a) the Department of Energy, other federal 

agencies, other government or private entities and to private sector employers to permit these entities to 

retrieve records required by NIOSH; (b) Identified witnesses as designated by NlOSH so that these 

individuals can provide information to assist with the evaluation of SEC petitions; (c) contractors assisting 

NIOSH; (d) collaborating researchers, under certain limited circumstances to conduct further investigations; 

(e) Federal, state and local agencies for law enforcement purposes; and (f) a Member of Congress or a 

Congressional staff member in response to a verified inquiry. 

This notice applies to all forms and informational requests that you may receive from NiOSH in connection 

with the evaluation of an SEC petition. 

Use of the NlOSH petition forms (A and B) is voluntaly but your provision of information required by these 

forms is mandatory for the consideration of a petition, as specffled under 42 CFR Part 83. Petitions that fail to 

provide required information may not be considered by HHS. 

Name or Social Securii Number of First Petitioner: - 
pe: Horizons, Inc.; NIOSH Tracking Number 

I have no knowledge of any monitoring data for Horizons, Lnc. 

date signed 
CALIFORNIA ALL-PURPOSE ACKNOWLEDGMENT 

STATE OF CALIFORNIA - 1 

COUNTY OF -. -. - - 

1 ss 

On adL* 2007 before me, the undersigned, a Notary Public in and for 

- . said State personally appeared - - -, . . . 

Name(s) of Signer(s) 

Perso?aliy known to me OR proved to me on the basis of satisfactory evidence to be the person(s) 

whose narne(s) islare subscribed to the within 

instrument and acknowledged to me that 

heisheithey executed the same in hisiherltheir 

authorized capacity(ies), and that by hislherltheir 

signature(s) on the instrument the person(s), or the 

entity upon behalf of which the person@) acted, 

executed the instrument. 

\R1itness my 

- /' - - ,/ 

jnature of Notary 

I/ - . 

(Area above forofficiai notarial seal) Name (Typed or Printed) 

Capacity Claimed by Signer 

W Individual(s) 

Corporate Officer(s) - Title(s) 

Partner(s) 

Attorney-in-Fact 

Trustee(s) 

GuardianlConse~ator 

R Other: 

Signer is Representing: Name of person(s) or J. 

Entity(ies) - 

Description of Attached Document 

(Although this information is optional, it could prevent fraudulent 

attachment of this certificate to another document.) 

This certificate is for attachment to the document 

described below: 

Title or type of document SPE U 4c 

Expesul~~ - GHO~ ?~~(110)~ - 

Forrr\ B. 

Number of pages 

Date of document 07 Id03 

Signer(s) other than named above